Provider Demographics
NPI:1417047812
Name:JACOB, MARLIN (CRTT)
Entity Type:Individual
Prefix:
First Name:MARLIN
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:CRTT
Other - Prefix:
Other - First Name:MARLIN
Other - Middle Name:
Other - Last Name:MATTAPPILLIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRTT
Mailing Address - Street 1:418 GRENADINE WAY
Mailing Address - Street 2:
Mailing Address - City:HERCULES
Mailing Address - State:CA
Mailing Address - Zip Code:94547-2050
Mailing Address - Country:US
Mailing Address - Phone:510-245-7585
Mailing Address - Fax:
Practice Address - Street 1:418 GRENADINE WAY
Practice Address - Street 2:
Practice Address - City:HERCULES
Practice Address - State:CA
Practice Address - Zip Code:94547-2050
Practice Address - Country:US
Practice Address - Phone:510-245-7585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0418902278C0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2278C0205XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedCritical Care